Vital Signs - Unit 1 (Basics & TEMP) Flashcards
What are the 5 vital signs?
Body Temp, Pulse, Blood Pressure, Respirations and Pain
Why do we take vital signs?
To get an idea of what’s going on.
When to take vital signs?
per agency policy, doctor’s order’s, on admission (baseline), prior to discharge, when a client has a change in health status, before or after surgery or procedure, before and/or after giving certain medication, before/after nursing interventions, nursing judgment/PRN.
Body Temp = balance between heat ___ and heat ___ by the body.
Produced/lost.
What are the two types of body temps? Give examples!
Core (abdominal cavity, cranial, etc.) and Surface (temp of skin, mucous layer, etc.)
What is considered a normal temp?
98-98.6 F (but 97-100 can be normal, too.)
What are some factors that effect body heat production?
BMR (cost of energy of things such as breathing, eating, etc.), thyroxin output (produced by the thyroid), fever, Epi, etc.
What are the five most common sites for measuring temperature?
Oral, rectal, axillary, and tympanic and temporal!
Oral and Temporal Temps are most accurate. T/F?
True!
If a person has eaten or drank something hot or cold within 30 minutes of getting the temp, it’s fine. T/F?
False - you have to wait 30 minutes!
Oral Temp - least accessible and convenient. T/F?
False - it is the most accessible and convenient!
Rectal Temp - possible perforation of the ___. It is also ____.
Bowel/embarrassment.
With a rectal temp, we can walk away while it’s being done. T/F?
False - we have to stay there!
Axillary Temp - least safe and very invasive. T/F?
False - it is very safe and very non-invasive!
Tympanic Membrane Temp - it is __ accessible, reflects the __ temp, and is very fast.
readily/core.
Bladder and esophageal temps - most or least reliable?
Most!
Which temp is best for older people?
Axillary!
What are the 5 types of thermometers?
Electronic, Tympanic Membrane, Chemical Disposable, Temperature Sensitive Tape, and Mercury
What regulates the body temp? Think anatomy….
Shell and Core, Hypothalamus, Sensory Receptors.
Temp Set Point - it is the …
control center of body temp level at which the hypothalamus maintains temp.
If we get too cold, __ is released.
Epi (vasoconstriction.)
If we get too warm, we ___.
Sweat (vasodilation.)
What are some factors affecting body temp?
Age, diurnal variation (circadian rhythms), exercise, hormones, stress, environment, etc.
Around what time of day are our temps the highest and lowest?
4p-8p = highest.
2-6 AM = lowest.
What are the four common types of Temps?
Intermittent, Remittent, Relapsing, Constant.
Intermittent Fever - def
Body temp fluctuates between periods of fever and no fever.
Remittent Fever - def
body temp fluctuates more than 3.6 degrees above normal and does not go back to normal between fluctuations. It is above 102.2 and doesn’t go below that.
Relapsing Fever - Def
body temp returns to normal for at least a day, then comes back.
Constant fever -def
body temps remains constantly elevated, but always less than 3.6 degrees (doesn’t go above 102.2)
What are some symptoms of a fever?
Increased HR, hot/dry skin, thirst, flushed face, etc.
Infant fever - above ___ is considered signifiant.
100.4
Infants and children are at a greater risk for febrile convulsions as the fever is elevating. T/F?
True!
Adult __ - ___ = low grade favor.
98.8-100.4
Above __ = significant fever.
100.4
Above ___ = Hyperpyrexia.
105.8
Nursing Interventions for Clients with fever - what are some?
Monitor vital signs frequently, provide adequate nutrition and fluids, measure input and output, remove excess blankets unless chilled or shivering.
Hyperthermia = non-regulated elevation in body temp with an imbalance between heat gain and heat loss. T/F?
True!
Hyperthermia - set point is/is not elevated?
Is not!
Neurogenic Fever - fever that is not elevating the set point. T/F?
True!
What are some heat exhaustion symptoms?
S&S weakness, fatigue, headache, giddiness, anorexia, nausea, etc.
Heat stroke - symptoms?
Hot, dry skin, absence of sweating, neurological symptoms - confusion, coma, seizures, acute renal failure, etc.
Malignant Fever - def
autosomal dominant genetic disorder that affects calcium levels within the skeletal muscle - occurs with administration of anesthesia. Dantrolene is given.
How do we treat hypothermia?
Prevent is, warm air spray, cooling blanket, etc.
Hypothermia - decrease what?
Body temp, pulse, and respirations.
Hypothermia - what else is a part of this?
Severe shivering (initially), feelings of cold and chills, hypotension, disorientation, etc.
How do we treat a patient with hypothermia?
Provide a warm environment, provide dry clothing, apply warm blankets, cover the scalp with a cap or turban, etc.
